17. Dizziness/vertigo

Question 1

what are the 4 subtypes of ‘dizziness’?

Answer 1

vertigo, disequilibrium, presyncope and psychological dizziness

Question 2

causes of vertigo

Answer 2

Peripheral (vestibular) causes of vertigo:
- Benign paroxysmal positional vertigo
- Ménière’s disease
- Vestibular neuronitis
- Labyrinthitis
- Acoustic neuroma

Central causes of vertigo:
- Posterior circulation infarction (stroke), particularly AICA
- Tumour
- Multiple sclerosis
- Vestibular migraine

Question 3

causes of presyncope

Answer 3

reflex
orthostatic
cardiogenic

Question 4

causes of disequilibrium

Answer 4

Parkinsons
Diabetes mellitus

Question 5

causes psychological dizziness

Answer 5

Depression
Anxiety
Hyperventilation syndrome

Question 6

History taking dizziness/vertigo

Answer 6

PC: room spinning? Lightheaded? Unsteady? Like you’ll faint?
HoPC: speed of onset? Duration? Hearing loss? Tinnitus? Coordination impairment? Change to the way you walk? Associated with nausea? Does it occur with movement of the head? How is your vision? double vision? How is your balance? How is your hearing? Any changes to sensation particularly in you legs and feet?chest pain? exertional?

MHx: diabetes? Heart problems? CVS disease? AF (stroke)?

DHx: drugs that can cause postural hypotension

FHx: parkinsons disease, heart probs-early death

Question 7

examination dizziness/vertigo

Answer 7

ear - ?infection

UL and LL and CN ?other defecits –> central cause of vertigo
- rombergs ?proprioception or vestibular problem

Cerebellar examination

HINTS examination ?central vs peripheral vertigo
HI – Head Impulse
N – Nystagmus
TS – Test of Skew

Cardiovascular exam to assess for cardiovascular causes of dizziness

Question 8

symptom onset peripheral vs central vertigo

Answer 8

peripheral = sudden onset

central = gradual onset except stroke

Question 9

duration of symptoms central vs peripheral vertigo

Answer 9

peripheral = short

central = persistent

Question 10

hearing loss or tinnitus , more likely in peripheral or central vertogo

Answer 10

peripheral (except BBPV)

Question 11

coordiantion central vs peripheral vertigo

Answer 11

peripheral = coordination intact

central = coordination impaired

Question 12

presence of nausea central vs peripherla vertigo

Answer 12

peripheral = more severe

central = mild

Question 13

what is the HINTS examiantion

Answer 13

The HINTS examination can be used to distinguish between central and peripheral vertigo. It stands for:
HI – Head Impulse
N – Nystagmus
TS – Test of Skew

Question 14

Head impulse HINTS

Answer 14

pt look at examiners nose

examiner jerks head 10-20 degrees

normal vetsibualr system = eyes stay fixed on examiners nose

In a patient with an abnormally functioning vestibular system (e.g., vestibular neuronitis or labyrinthitis), the eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner.
The head impulse test helps diagnose a peripheral cause of vertigo but will be normal if the patient has no current symptoms or a central cause of vertigo.

Question 15

Nystagmus HINTS

Answer 15

Nystagmus can be demonstrated by having the patient look left and right. The eyes rapidly saccade or oscillate, meaning they shake side to side as they try to settle into place.

A few beats can be normal.

Unilateral horizontal nystagmus is more likely to be a peripheral cause.

Bilateral or vertical nystagmus suggests a central cause.

Question 16

nystagmus central vs peripheral vertigo

Answer 16

Unilateral unidirectional horizontal nystagmus is more likely to be a peripheral cause.

Bilateral or vertical nystagmus suggests a central cause.

Question 17

test of skew HINTS

Answer 17

alternate cover test

pt fix eyes on examiners nose

examiner covers one eye at a time

normal = eyes remain fixed

central cause = vertical correction when an eye is uncovered (the eye has drifted up or down and needs to move vertically to fix on the nose when uncovered)

Question 18

elderly ot dizziness on extension of the neck

Answer 18

Vertebrobasilar ischaemia

Question 19

features BPPV

Answer 19

sudden onset of dizziness and vertigo triggered by changes in head position

each episode typically lasts 10-20 seconds

Question 20

examination BPPV

Answer 20

positive Dix-Hallpike manoeuvre

Question 21

management BPPV

Answer 21

responds spontaneously in weeks/months

Epley manoeuvre (successful in around 80% of cases)

teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises

Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value.

Question 22

features of peripheral causes of vetigo

Answer 22

sudden onset
short duration
hearing loss/tinnitus may be assocoated
coordiantion nromal
severe nausea

Question 23

Presentation menieres disease

Answer 23

Ménière’s disease often starts as unilateral and progresses to bilateral.

recurrent attacks of:
Hearing loss
Vertigo
Tinnitus

a feeling of fullness in the ear
Unexplained falls (“drop attacks”) without loss of consciousness
Imbalance, which can persist after episodes of vertigo resolve
Spontaneous nystagmus may be seen during an acute attack. This is usually in one direction (unidirectional).

getting worse over time
short episodes –> permenant

not associated with movement

Question 24

pathophysiology menieres disease

Answer 24

Ménière’s disease is associated with the excessive buildup of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals. This increased pressure of the endolymph is called endolymphatic hydrops.

Question 25

plan ?menieres disease

Answer 25

Plan:
Investigation
1. Refer to ENT for diagnosis (clinical)
+. Audiology to evaluate hearing loss

Management
Acute attacks
1. Prochlorperazine
2. Antihistamines (eg cyclizine, cinnarizine, promethazine)

Prophylaxis:
1. Betahistine (H3 antagonist)

Question 26

pathophysiology labrythnitis

Answer 26

Labyrinthitis refers to inflammation of the bony labyrinth of the inner ear, including the semicircular canals, vestibule (middle section) and cochlea. The inflammation is usually attributed to a viral upper respiratory tract infection.

Question 27

presentation labrynthitis

Answer 27

acute attacks of:
Vertigo

may have:
Hearing loss
Tinnitus

following a URTI or more rarely otitis media or meningitis

Patients may have symptoms associated with the causative virus, such as a cough, sore throat and blocked nose.

Question 28

diagnosis labryntihitis

Answer 28

clinical diagnosis

It is important to exclude a central cause of the vertigo.

The head impulse test can be used to diagnose peripheral causes of vertigo, resulting from problems with the vestibular system (e.g., vestibular neuronitis or labyrinthitis).

Question 29

management labryntihitis

Answer 29

3 days symptom management
Options for managing symptoms are:

Prochlorperazine
Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

Question 30

Presentation vestibular neuronitis

Answer 30

Initially, vertigo may be constant, after which it is triggered or worsened by head movement. It is often associated with:

Nausea and vomiting (may be severe)
Balance problems

Question 31

what is different about labrynthitis and vestibular neuronitis? what is simialr?

Answer 31

labrynthitis has hearing loss and tinnitus, VN doesn’t as it is only the VESTIBULAR nerve involved so no hearing issue

both triggered by infection

Question 32

management vestibular neuronitis

Answer 32

buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases

a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe cases

Question 33

How can a diagnosis of MS be made?

Answer 33

Evidence of one episodes with obj results eg MRI w contrast or Oligoclonal bands in CSF

PLUS

evidence of another episode (obj results or a reasonable history)

Question 34

symptoms MS

Answer 34

visual:
- optic neuritis (vision loss, colour blindness, retro-orbital pain)
- uhthoffs phenomenen
- internuclear opthalmoplegia

sensory:
- pins/needles
- numbness
- trigeminal neuralgia
- Lhermitte’s syndrome: paresthesia in limbs on neck flexion

motor:
- spastic weakness: most commonly seen in the legs

cerebellar
- ataxia
- tremor

other
- urinary incontinence
- sexual dysfunction
- intellectual deterioration

Question 35

types of MS?

Answer 35

Relapsing-remitting disease
- acute attacks (e.g. last 1-2 months) followed by periods of remission

Secondary progressive disease
- RR then neurological signs and symptoms between relapses
- gait and bladder disorders are generally seen

Primary progressive disease
- progressive deterioration from onset
- more common in older people

Question 36

pathophysiology MS

Answer 36

Demyelination
Acquired, chronic, immune mediated

Question 37

LP result MS

Answer 37

Oligoclonal bands in CSF

Question 38

Invetsigations MS

Answer 38

MRI with contrast

Oligoclonal bands in CSF

Question 39

management MS

Answer 39

Acute relapse
1st line: oral methylprednisolone 0.5g daily for 5 days
If failed or not tolerated on severe relapse: admission for IV methylprednisolone

Disease modifying drugs such as Natalizumab (a recombinant monoclonal antibody) or Fingolimod

Question 40

management spasticity MS

Answer 40

1st line: consider baclofen or gabapentin (off label)

Question 41

What is the scale used in MS to monitor symptoms

Answer 41

Expanded Disability Status Scale (EDSS)
This is based on 8 functional systems:
Pyramidal
Cerebellar
Brainstem
Sensory
Bowel and bladder
Vision
Cerebral
Other

Question 42

Management bladder dysfunction MS

Answer 42

may take the form of urgency, incontinence, overflow etc

get USS first to assess bladder emptying - anticholinergics may worsen symptoms in some patients

if significant residual volume → intermittent self-catheterisation

if no significant residual volume → anticholinergics may improve urinary frequency

Question 43

what is a vestibular migraine?

Answer 43

A vestibular migraine, or migrainous vertigo, is a type of migraine that mainly presents with dizziness symptoms. Approximately 40% of people who experience migraines have problems with dizziness and/or balance at some point. This can be before, during, after, or independent of the migraine.

Question 44

what type of stroke may have vertigo as a feature

Answer 44

Anterior inferior cerebellar artery (lateral pontine syndrome)

Ipsilateral: facial paralysis and deafness {vertigo and vomiting, ipsilateral facial paralysis and deafness }

Pontine = paralysis

Question 45

presentation acoustic neuroma/Vestibular schwannoma

Answer 45

Cranial nerve V (trigeminal) afferent (corneal) - main one for corneal

Cranial nerve VII (facial) efferent (corneal) and facial palsy

Cranial nerve VIII (vestibulocochlear) vertigo, unilateral sensorineural hearing loss, unilateral tinnitus

Question 46

what nerves are involved with the corneal reflex

Answer 46

Cranial nerve V (trigeminal) afferent (corneal) - main one for corneal

Cranial nerve VII (facial) efferent (corneal)

Question 47

association bilateral vestibular schwannoma

Answer 47

neurofibromatosis type 2

Question 48

plan ?vestibular shwannoma

Answer 48

urgent rf to ENT
MRI of the cerebellopontine angle

Audiometry is also important as only 5% of patients will have a normal audiogram.

Management is with either surgery, radiotherapy or observation.